ACHC - Medicare Deeming Authority for Home Health, Hospice, & DMEPOS

Accreditation Process

Eligibility Criteria

Any home care or alternate site organization may apply for an ACHC accreditation survey if it meets all of the following eligibility requirements:

Your organization has been actively providing in-home and/or alternate site services and has served a minimum of ten (10) clients with seven (7) active clients before submitting an application.
Your organization agrees to grant ACHC and/or its designated agent’s full access to all records (including client and personnel) that are necessary to ascertain compliance with the standards.
Your organization agrees to pay fees according to the terms specified in the Contract for Survey.
Your organization agrees to submit applications for all branch offices.
Your organization must be operating within the United States and/or its territories.

1. Register for the ACHC Accreditation Standards

The first step in our accreditation process is to obtain the ACHC Accreditation Standards, specific to the services you provide. After registering, we will email you a username and password for your personal website; Customer Central. This website contains all the forms and information necessary to start the accreditation process. ACHC will also send you a confirmation email containing the name and contact information for your Account Manager. This individual will be available to assist you with any questions you may have and will guide you through the accreditation process from start to finish.

2. Preparing your PER

Your organization will complete a self-assessment known as the Preliminary Evidence Report (PER), as part of the preparation process. Preparation time will vary, depending on your organization’s resources, ability to stay focused on a systematic plan of evaluating compliance with ACHC standards and making the necessary changes in policy and practice to bring the company into compliance. Here are a few tips to help your company through the preparation process:

Use a team approach. For internal use only, ACHC standards may be reproduced and distributed among the team members. Staff should thoroughly read the sections that contain the Accreditation Policies and Procedures, the Interpretive Guide to Standards, and the Preliminary Evidence Report (PER).

Develop an action plan. Your staff will need guidance in conducting the self-assessment and correction of areas that need implementation or improvement. Make sure they understand the need for compliance with policy, process and performance. Policies should reflect actual processes of how you operate and function within your business and how delivery of services is carried out. Performance will measure how well you provide services to clients.

Meet on a regularly scheduled basis to determine progress and exchange ideas. Identify strengths and weaknesses so that appropriate corrective actions may be made. Assess progress and PER preparation to identify specific areas that may need more attention prior to the survey visit.

Talk with associates experienced in the accreditation process. Many good tips can be learned and obtained through networking. If you have any questions about a standard, please contact our office.

Meet with staff to discuss the survey visit and questions. The better you coach your staff the better they will respond during the survey visit. It is normal, however, to have some anxiety. Assure your staff that ACHC surveyors will have a positive attitude and will be at your organization to measure compliance with ACHC standards and provide an educational and consultative approach.

Completion of survey preparation means that you are able to demonstrate that your organization fulfills its mission, practices what its policies state and complies with the ACHC standards.

3. Submission of the Application, Deposit and PER

Once you have reviewed all of the information on your customer central website, there are certain items that must be submitted to your Account Manager to start the accreditation process: the completed application, completed Preliminary Evidence Report (PER), a non-refundable $1,500 deposit, and any other program specific items. The accreditation application is used to determine the demographic information about your company. The PER, when completed, is a compilation of ACHC’s standards and your company’s policies. It is preferred that the PER be submitted electronically, but it may also be submitted as a hard copy for a minimal fee. All the instructions on how to complete your application and PER will be available on customer central. The $1,500 deposit is non-refundable and is applied toward your accreditation fees.

4. Fee Estimate and Contract

Once your application, PER and deposit are received, your Account Manager reviews them for completion. Your Account Manager then generates a fee estimate based on the demographics from your application and will email this estimate to you. Following the fee estimate, your contract for accreditation is created. The contract spells out our obligations to you as well as your obligations to us, and must be signed and returned within seven calendar days from the date it was sent to you. We will then generate an invoice showing the remaining accreditation fees due within 30 days after the contract is signed.
All accreditation fees must be paid in full before ACHC releases any accreditation decisions.

5. Scheduling the Survey

Surveys are not scheduled until the contract is signed and returned to ACHC. Surveys will be scheduled approximately 3-7 months from the date the contract was signed. Please note that all surveys are unannounced (with the exception of Sleep Lab and initial licensure surveys for Home Health agencies) and will be conducted during normal business hours. You will, however, have the opportunity to select 10 blackout dates on your application. Although these dates aren’t guaranteed, ACHC will make every effort not to schedule the survey on those dates. ACHC does not conduct surveys on major holidays. Surveyors will be selected based on the services your organization provides and they will be well qualified in that field(s). Multiple surveyors may be required if you are providing multiple services.

6. Desk Review

After the survey is scheduled, we will send the selected surveyor the application and PER that you submitted for a thorough review of all your policies and company information. They will complete a desk review, which includes a summary of any standards that may not be met, prior to conducting the on site survey. This gives you a chance to make any necessary changes prior to the survey. You will receive the desk review results at least 30 days prior the survey. You should make the appropriate corrections, and have them available to your surveyor at the time of survey. Your surveyor will then conduct a final assessment of these corrections during the onsite visit.

7. On Site Survey

A survey agenda consists of the following:

Opening Conference
Tour of the Facility
Company QI/Performance Improvement Presentation
Review any PER correction (if applicable)
Client/Patient Home Visits
Client/Patient record reviews
Personnel record reviews
Interview with staff and management
Exit conference

8. Scoring Your Survey

Once the survey is complete, the surveyor submits all of his/her findings to your Account Manager to be scored and summarized. Survey results can only be released when fees are paid in full. Based on scoring criteria, there are three different decisions that can be reached:

Accredited – Very minimal or no deficiencies found. Overall the company is compliant with ACHC standards. Accreditation is granted, but a POC (Plan of Correction) for any deficiencies found must be developed and sent to your Account Manager within 30 days.
Deferred – Enough deficiencies that the company did not score high enough for accreditation status. The company will have an opportunity to submit a POC (Plan of Correction) for all standards that were “partially met” or “not met” and this POC will be reviewed by a clinical advisor. If all deficiencies have been resolved, the company will be granted accreditation.
Denied – Many severe deficiencies that cause a company to be outside of the deferred range. In this instance, the company is out of compliance with ACHC standards and must re-apply for accreditation. All fees and application documents must be re-submitted in order to re-apply.

9. Accreditation Status

Your Account Manager will submit the approval letter, certificate, copy of your summary of findings and window decals to you by mail. We will also forward ACHC’s logos and advertising policies to you as well. The accreditation is granted for three years with no annual fees.

10. Renewal

ACHC will send a renewal letter describing how to begin the renewal process before your accreditation expires. You will need to send ACHC a renewal application, completed PER and deposit to begin the renewal process.